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5/22/2012 @ 11:45AM14,903 views

Why The Media 'Can't Handle the Truth' About Accretive Health

Contributor’s Note: We at insideARM.com have been covering the Accretive Health (NYSE:AH) “scandal” since Minnesota Attorney General Lori Swanson first published her 100+ page report indicting (in the common, not legal sense of the word) Accretive for badgering patients into making payments and other debt collection abuses [sic]–or at least that’s what an overwhelming majority of mainstream media outlets heard when they rained down invective in headline after headline on the Illinois-based revenue cycle management company.

But in reality the scandalous aspect of the Accretive yarn doesn’t lie with the subject of those stories; it falls squarely upon reporters and Ms. Swanson herself for a failure of clear vision. In the words of Col. Nathan R. Jessup in A Few Good Men (1992): “You can’t handle the truth!” I would argue that at the precise moment in Rob Reiner’s film when Jack Nicholson’s Jessup utters those now-iconic words, he’s 100 percent correct. Jessup’s problem, however is that he also committed a crime under military law. But those things–the excited utterance and the crime itself are, for an instant, mutually exclusive. Tom Cruise and Demi Moore and all the fictional American civilians in the motion picture cannot, in fact, handle the truth–AND Col. Jessup’s actions led to the death of one of his men.

If one were to produce “A Few Bad Debt Collectors” to chronicle the saga that has unfolded around Accretive Health, the story line would be much the same… well, half of it. Journalists across the country and the most powerful lawyer in the State of Minnesota can’t handle the truth about Accretive. Too bad (regarding box office receipts for our made-up blockbuster) that Accretive, unlike Jack, didn’t commit any crime.

When the Minnesota Attorney General’s office issued a scathing report criticizing how a hospital contractor managed the collection of patient fees, it inadvertently attacked what are correctly understood as vital health care industry best practices for revenue cycle management (RCM).

Last month Minnesota Attorney General Lori Swanson released a six-volume “compliance review” of Minneapolis-based Fairview Health Services, a not-for-profit chain of seven hospitals and more than 40 clinics, and its contractual relationship with Accretive Health, a publicly traded firm offering revenue cycle management services for hospitals.

Swanson’s report directed most of its ire at Accretive, the out-of-state company, rather than the hospital/clinic system based in her state, even though many of the policies and procedures her office found repugnant were in place before Accretive took over management of Fairview’s revenue cycle operations. The national media jumped upon the more salacious parts of the compliance review report upon its release and Accretive’s stock fell by half in the day’s following the AG’s announcement.

Over the last 10 days, Accretive has fought back, launching a counter public relations effort, denying the charges, accusing the Attorney General of acting in bad faith and launching an initiative to establish national standards for patient financial practices.

The Attorney General must be feeling the heat. In the midst of Accretive’s PR campaign, the AG’s hometown paper, The Minneapolis Star Tribune (whose pro-consumer sympathies are well documented), last week published a story about Fairview complaints against Accretive that was nothing more than a regurgitation of the charges released in April. The Attorney General has now added a link to her main web page, actively soliciting the public for complaints about Accretive.

Attorney General Swanson has yet to file any civil or criminal complaints against Accretive related to the release of the report, although in January her office did file a lawsuit against Accretive for losing a laptop that contained patient information. Despite more than 113 pages of accusations and supporting material dealing with a company in one of the most regulated industries in the United States there has not been one new lawsuit or criminal charge.

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In the last InsideArm blog post on Forbes, senior editor Patrick Lunsford writes: “What Accretive is accused of doing on behalf of Fairview is indefensible. But there is little to indicate that these practices are standard for the company.” Are you stepping back from that position by suggesting these practices are normal in the industry?

The “You can’t handle the truth” rhetoric may be entertaining, but there’s a problem. Studies have shown, and it only stands to reason, that overly-aggressive collection tactics may cause people to avoid seeking care for themselves or even the family members in their care. Therefore, it’s not too far out of an argument to suggest that “crimes” may indeed have-been/are-being committed. To be frank, that list could include endangering the welfare of a vulnerable elderly person or child; reckless endangerment and/or negligent injury, up to and including negligent homicide. Try and handle that truth, why don’t you?

To your first point about Patrick’s post, take note of the fact that Patrick explicitly says “What Accretive is ACCUSED (emphasis mine) of doing…” More importantly, you didn’t cite the paragraph Patrick wrote immediately following the one you cite. It reads:

“And there’s that word again: “report.” Swanson did not announce a lawsuit or other legal action against Accretive (or Fairview, for that matter) Tuesday. Her office merely made public a report with a lot of detailed accusations, and a high-profile newspaper article was published shortly thereafter.”

I don’t think we’ve stepped back from that position at all. Regardless it is not uncommon for our various contributors–here on Forbes or on insideARM–to take slightly (or even radically) different points of view on the same topic–though that’s hardly the case with Accretive.

Second, you allude to studies that show that “overly-aggressive collection tactics” may deter patients from seeking care. That “may” be the case. Feel free to share links to those studies you reference here. It is true, of course, and well documented, that a number of other factors discourage patients from seeking routine, preventative care; they include un- or underinsured status, access to providers, pre-existing conditions, immigration status, education levels, employment status, access to transportation, etc.

What I am not convinced by is your argument that Accretive may in fact have committed a crime–and that that crime may extend all the way to negligent homicide. There is no legal precedent that I am aware of where a patient’s conscious decision to NOT seek care made a healthcare organization or service provider criminally liable for that patient’s choice. [NOTE: I am not an attorney; I'm just stating what I know from my own experience/research.]

So we return to facts, and one fact is crystal clear here: AG Swanson’s “report” was not then (and to this day has not been) accompanied by any criminal charges or a lawsuit.

Finally, if we return to the list of documented, contributing factors I cited above for why patients elect to defer care, your logic would suggest that–for example–insurance companies that charge high premiums, employers who do not provide sponsored insurance coverage, states that have sued the Federal Government over the constitutionality of the PPACA, doctors that charge “too much” for vaccinations, or OPEC for driving up gasoline prices might all be held criminally liable for a patient who decided to skip routine check ups and subsequently got sick and died.

You suggest I should try to handle that truth. Fair enough. I just don’t see the legal truth in your argument.

If the argument is, explicitly or implicitly: “I don’t care how high the bodies are stacking up, it’s no skin off my secret sauce,” then there’s a problem.

It’s been well-established in medicine for a number of years that illness is caused by a multiplicity of factors, including those that involve personal decisions of the patient. There is never a single cause, and it seems rather unsophisticated to use the rhetoric “conscious decision NOT to seek healthcare” as a single cause in the same way that people used to assign single causes to disease. Patients make decisions based on a number of factors of course, but certainly engaging them in a battle of wills over payment details–when they’re already feeling vulnerable under threat of illness–is not likely to call forth their very best decision-making abilities (nor healing abilities, for that matter).

You missed the nuance in my argument about personal responsiblity and shame and how the two are intertwined. I should have said personal accountability, as accountability is a more recent word that stems from a business/legal history. It’s those who demand accountability who inevitably are pointing their fingers outward, judging and shaming. Those who would gladly take personal responsiblity may become unaccountable to you in the short term because of the way they’re treated. They recoil from the notion of someone effectively saying: “If it weren’t for me here in your hospital room demanding payment, I know you’d probably try to weasel out of it, chum.” There’s no grace, no trust, no alternative but to acquiesce in the assumption that the only behavior that ever can be guaranteed is that which is enforced by external pressure. That’s a pretty depressing position, ultimately.

There are real people who complained to the Minnesota Attorney General about their treatment–complained bitterly in some instances. If their suffering and their sense of what was/is important to them during a difficult time in their lives is to have any meaning, we should be taking a look at what they have to say. I’d say that’s a wiser and more compassionate approach then worrying about Accretive Health’s feelings. Despite the Supreme Court ruling that corporations are people, corporations in actuality have no feelings, being abstractions and all. An abstraction can’t even be insulted. Although, it is tempting to contemplate driving one of them to suicide, something that couldn’t be countenanced doing to a real person. Sadly, there are real news reports of people who have taken their own lives over medical debt, but no reports of a corporation leaping to its own death.

And so the bodies continue to stack up….

Lastly, I’d ask you to consider something else. A substantial and growing list of patients or family members who in their feelings of vulnerability were approached with a simple expression of compassion (perhaps by a doctor, nurse, or other health-care professional) became so taken by that simple expression that they wanted to express their gratitude to the facility. Therein lies the source of hundreds of millions–no, billions–in donations given to medical institutions by grateful patients and families–whether or not their loved one survived. If you were to press me for one fact that was crystal clear–and I hesitate to return to the pedestrian world of debt collection, traditional or otherwise–it’s that this sort of thing will never happen with the profit-seeking bedside roamers in hospitals who don’t belong there in the first place.

Wading through the great deal of speculation, conjecture and unsupported foolery in the comments of D.D. would be too daunting and would not likely work to deter you in your diatribe against the viscous corporate suit walking the halls of your local hospital and daring to approach a patient.

To respond to the insinuation that AH employees can bee in the hospital and have access to patient information, I could explain to you the concepts of agency relationship and additionally cite how HIPPA allows contracted agents to act on the hospitals behalf. I won’t waste my time as this would likely be glossed over in another rambling repsonse.

What I will respond to is corporations having no feelings. True, corporations do not have feelings, but the people that work for them do. It is quite disheartening to those employees, who while performing their duties also have screened uninsured and underinsured patients for programs that will pay for there medical bills, to hear that the good work they are doing to help keep the hospital functioning be berated by media outlets that know nothing of the situation.

The largest part of AH’s business model deals with insurance billing and plugging the holes that insurance companies attempt to use to wiggle out of payment for the people they insure. The next biggest part is patient financial advocacy. Counselors work to identify programs (Medicaid, COBRA, hospital charity, etc,.) that patients may qualify for yet are unaware that they exist or would even apply to them. AH has been able to find these programs for over 85% of the self-pay patients that they screen to the tune of over 250,000 patients.

Is this the picture that AG Swanson wishes to paint. No. She has merely distorted the fine work that AH has done in her state for Fairview and its patients. And why? To score some political points and paint herself as the great crusader for patient’s rights. The result of her actions will actually hurt her constituents. Fairview needed the specialization that AH brought to the table and now it is left to fend for itself. Kudos to you Ms. Swanson, and kudos to you Dismissal in your well-rounded, yet completely off-base understanding of healthcare.

It may as you suggest that insurance companies will be making more money in the short term with Accretive out of the picture at Fairview. But neither Accretive Health nor insurance companies make their money by providing actual patient care. That lack of contribution to healing is the argument people use for doing away with all such 3rd parties and relying on a single payer system, and it’s an argument I agree with.

The “viscous [sic] corporate suits” you refer to walking the halls of the hospital would have been much more obvious than the creepers who patients actually came into contact with. If you listened to the testimony at Senator Franken’s hearing as I did, you would have learned that these people slipped unannounced past nursing staff into patient rooms where the patients were in various stages of undress or even on a morphine drip. Who does this sort of thing?

If you are interested, I recommend you watch the hearing in its entirety here: http://www.theuptake.org/2012/05/30/sen-franken-holds-hearing-examining-patient-access-to-care-and-privacy/

Al Franken, showing what I thought was excessive politeness toward Accretive Health’s VP, read two glowing testimonial letters Accretive provided from patients. In hearing those testimonials, I couldn’t help but think of the psychology someone who is both vulnerable and potentially under duress. The extreme example of that is those who identify with their potential tormentors. The Stockholm syndrome has has been exhibited by victims who have been abducted by kidnappers and serial killers. In one vivid case I recall hearing about, extreme cooperation and identification with the serial killer reportedly had the effect of sparaing a young woman’s life as the killer inexplicably released her (traumatized, to be sure).

I also am reminded of the hilarious scene from the movie Young Frankenstein, where the old blind man played by Gene Hackman prays: “A visitor is all I ask. A temporary companion to help me pass a few short hours of my lonely life.” Someone who shows up unexpectedly in your hospital room, not for a medical or social call, and having little empathy for your illness, is a bit like the monster breaking down the door of this old man’s shack. Some patients, by a sense of aloneness and fear/confusion over a life-altering diagnosis, are going to be grateful for any company they receive, including debt collectors. That of course isn’t humorous, it’s pretty pathetic.

I’m trying hard to change my perspective such that I see debt collectors more as human beings–which you claim they have feelings too, and Senator Franken mentioned something similar. Generally, I haven’t been getting a lot of help here in that regard.

I was impressed with professor Goodwin’s testimony at the hearing. There was one zinger that she threw out there that’s hard to ignore: “We know there has been a history in this country where African Americans have literally died on the steps of hospitals.” One case I thought of was of a young African American named Maltheus Avery. Quoting from the Carolina Times from December 9th, 1950: ‎”When Avery arrived at Duke he was refused admittance, hospital officials say, because there was no bed space available. They stated that only a small space is allotted Negroes.” I’m pleased to hear Senator Franken is going to pursue his inquiry further into hospital collection practices. There are today more subtle ways to effectively deny treatment: make the patient feel shamed and uncomfortable such that they leave and don’t return. The economically disadvantaged become largely those who are discriminated against, and the results of that discrimination can become for some individuals just as deadly as during the time professor Goodwin refers to.

If you think my arguments are extreme, just look at what has been happening with hospitals filing lawsuits against patients rather than work out reasonable payment arrangements, ultimately destroying people’s livelihoods along with their credit ratings. Nastiness is compounded by nastiness, as employers use those ratings to deny employment or even to fire people from their jobs. Reported on the CBS Evening News last night, 60% of employers now run credit checks on employees. Those who are out of work in this tough economy and necessarily have incurred debt to feed themselves or their families are in a Catch-22. It’s more than a Catch-22: it’s a Kafkaesque nightmare if you follow it to its logical conclusion. As more and more employers are denying employment based on credit checks, unemployed persons will be stuck in a permanent limbo of unemployment and poverty–some will be unable to ever contemplate having a family or a normal life again. And then, to add insult to injury, from their executive suites some will thump their chests and exclaim: “They brought all of this on themselves: poverty, loneliness, untreated illness… death.” What a world we live in.

Lunsford’s previous article states, “What Accretive is accused of doing on behalf of Fairview is indefensible, bu there is little to indicate that these practices are standard for the company.” You apparently missed the point that these were accusations, unproven accusations at that. This article does not step back from the fact that Ms. Swanson’s accusations are terrible, only that in an effort to play the populace card, media outlets have ran with the story that the big bad debt collector is denying care to patients- which is also a completely erroneous claim.

Research Ms. Swanson and you’ll find that these are fer typical tactics. Her motto, “If you lack the evidence to try a case in the judicial courts, try the case in the court of public opinion were the burden of proof is non-existent.

If asking for payment for services rendered is a crime, then everyone who receives a paycheck is guilty of the same crime.

Excellent article from people who do more than just read the headlines and who actually attempt to understand the whole picture.